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Montana rates for HCPCS A9569

Technetium Tc-99m exametazime labeled autologous white blood cells, diagnostic, per study dose

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,707.11 / $1,707.11 / $1,707.11
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,675.42 / $3,989.66 / $10,166.60
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,748.25 / $1,748.25 / $2,821.44
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,675.42 / $3,989.66 / $10,166.60
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,563.80 / $2,215.42 / $3,039.62
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,713.97 / $1,713.97 / $1,713.97